Healthcare Provider Details

I. General information

NPI: 1043099757
Provider Name (Legal Business Name): JOURNEY OF LIFE TRANSFORMATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 S PEACE HAVEN RD
WINSTON SALEM NC
27104-4439
US

IV. Provider business mailing address

178 S PEACE HAVEN RD
WINSTON SALEM NC
27104-4439
US

V. Phone/Fax

Practice location:
  • Phone: 336-995-1418
  • Fax: 336-448-5386
Mailing address:
  • Phone: 336-995-1418
  • Fax: 336-448-5386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. KIMBERLY NEAL
Title or Position: OWNER/EXECUTIVE DIRECTOR
Credential:
Phone: 336-995-1418